Key Takeaways
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Even the highest-rated Medicare Advantage plans can include hidden or underestimated costs that catch you off guard if you don’t study the plan details carefully.
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In 2025, cost-sharing limits, drug coverage rules, and network restrictions vary widely between plans, and these factors can directly impact your total out-of-pocket expenses.
Why a Top-Rated Plan May Not Equal Affordable Care
Medicare Advantage plans often look appealing at first glance. They bundle Medicare Parts A and B, often include Part D prescription drug coverage, and add extras like dental or vision. Many even receive high ratings from the Centers for Medicare & Medicaid Services (CMS). A 4.5- or 5-star CMS rating suggests strong performance in areas like customer service, member satisfaction, and preventive care.
However, a top CMS rating does not necessarily mean a plan is affordable for you. Cost structures vary by plan, and what you end up paying can be higher than expected depending on your healthcare usage, provider access, and even the types of medications you need.
What the CMS Star Rating Tells You
CMS assigns star ratings from 1 to 5, with 5 being the highest. These ratings are updated annually and reflect performance in key areas:
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Management of chronic conditions
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Preventive services
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Customer service
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Member complaints and disenrollments
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Plan responsiveness
While these categories give a broad picture of quality, they don’t fully reflect the cost dynamics you face as a plan member. Plans with similar star ratings can have very different deductibles, copayments, and coinsurance.
Looking Beneath the Surface of Plan Costs
Medicare Advantage plans typically use one or more of the following cost-sharing structures:
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Monthly premiums (on top of your Part B premium)
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Annual deductibles for medical services and prescription drugs
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Copayments for visits, tests, and procedures
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Coinsurance for specialist care, durable medical equipment, or hospital stays
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Out-of-pocket maximums that cap your spending, but only for in-network care
These amounts vary dramatically between plans, even in the same county. A plan with a low deductible may charge higher copays. A plan with generous drug coverage might limit your provider choices. If you don’t compare details side by side, you could end up in a plan that’s costly in ways you didn’t anticipate.
1. Understanding the 2025 Out-of-Pocket Limits
In 2025, Medicare Advantage plans must set an annual limit on in-network out-of-pocket expenses. The current in-network cap is $9,350. If you use out-of-network services, your combined cap can go as high as $14,000.
This cap may sound reassuring, but hitting the maximum requires a large volume of services. Even before you reach it, you may face steep copays and coinsurance that accumulate rapidly.
What to check:
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How close are the copayments to $50 or more for specialty care?
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Is your preferred hospital considered in-network?
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Are there separate cost caps for medical vs. drug expenses?
2. Drug Costs Can Escalate Fast
Prescription drug coverage under Medicare Advantage plans often comes with tiered formularies. Your medication costs will vary depending on the tier your drug falls into. In 2025, the Part D deductible can be as high as $590. After that, your plan pays a portion of your drug costs during the initial coverage phase.
The biggest relief in 2025 is the introduction of a $2,000 out-of-pocket maximum for Part D drugs. Once you hit this amount, your plan covers 100% of your covered drug costs for the rest of the year. However, reaching this cap depends on your medication needs and pricing.
What to check:
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Are your current medications covered?
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Which tier are they in?
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Is prior authorization required?
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Are generics or preferred pharmacies incentivized?
3. Network Restrictions Can Trigger Extra Costs
Most Medicare Advantage plans use provider networks. Health Maintenance Organization (HMO) plans typically require referrals and limit you to in-network providers. Preferred Provider Organization (PPO) plans offer more flexibility, but out-of-network care is more expensive.
In rural or underserved areas, the “best” plan may still have limited in-network options. Seeing an out-of-network doctor may come with higher coinsurance or may not be covered at all unless it’s an emergency.
What to check:
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Is your current primary care provider in-network?
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What about your specialist?
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Are you required to get referrals?
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Does the plan have enough local providers?
4. Emergency and Urgent Care Coverage Isn’t Always Simple
While Medicare Advantage plans are required to cover emergency care anywhere in the U.S., urgent care can be a gray area. Some plans limit coverage to affiliated urgent care centers. If you travel frequently or live part of the year in another state, this can become a costly oversight.
What to check:
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How does the plan define urgent vs. emergency care?
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Are you covered during domestic travel?
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Will you pay more for out-of-area care?
5. Supplemental Benefits Aren’t Always Free
Many Medicare Advantage plans advertise extra benefits like:
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Dental
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Vision
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Hearing aids
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Fitness memberships
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Transportation
While these extras add appeal, some come with separate fees, restricted provider lists, or annual limits. For instance, dental coverage may include only cleanings and exams, with no coverage for root canals or dentures unless you pay extra.
What to check:
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What services are actually included?
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Are there annual caps or waiting periods?
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Do these benefits apply everywhere or only in certain locations?
6. Plan Changes Happen Every Year
Each year, Medicare Advantage plans submit their offerings to CMS for approval. This means premiums, benefits, drug formularies, and provider networks can change annually. Your 2025 plan may not look the same in 2026.
Every fall, you should receive an Annual Notice of Change (ANOC), typically by the end of September. This document outlines any upcoming modifications for the next plan year. If you overlook it, you may be surprised by higher costs or discontinued services.
What to check:
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Did your provider or hospital leave the network?
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Have your drug copays changed?
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Are benefits being reduced?
7. Dental and Vision Coverage Often Sounds Better Than It Is
Extra benefits are often headline features in Medicare Advantage marketing. Dental and vision are among the most common. However, many plans only cover basic services and require you to use a narrow network.
Comprehensive coverage for dentures, implants, glasses, or specialized exams may be either excluded or capped at low annual dollar limits.
What to check:
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Is coverage for complex procedures included?
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Can you see any provider or just a list of contracted ones?
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Are there separate deductibles for these services?
8. Timing Matters More Than You Think
The Annual Enrollment Period runs from October 15 to December 7 each year. During this window, you can switch plans or return to Original Medicare. Once that period closes, your options become limited unless you qualify for a Special Enrollment Period due to a qualifying event.
Failing to review or switch in time means you are locked into your current plan for another year, regardless of rising costs or reduced benefits.
What to do:
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Review the ANOC by early October.
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Compare plans using the Medicare Plan Finder or speak to a licensed agent.
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Decide before December 7 to secure your preferred coverage for January 1.
A Careful Approach Helps You Avoid Costly Surprises
Medicare Advantage plans may offer appealing features and high CMS star ratings, but those factors don’t guarantee low costs. By carefully reviewing provider networks, cost-sharing terms, drug coverage, and annual limits, you can avoid the shock of unexpected bills. The best plan for someone else may not suit your needs, especially if you have chronic conditions, travel frequently, or need specific medications.
Take the time to compare your options thoroughly. If you’re unsure about the fine print or how costs could affect your situation, speak with a licensed agent listed on this website for personalized help.
